DEPARTMENT OF HEALTH & HUMAN SERVICES
Date:
Public Health Service
Centers for Disease Control
and Prevention (CDC)
Memorandum
January 15, 2003
From: WHO Collaborating Center for
Research, Training and Eradication of Dracunculiasis
Subject: GUINEA WORM WRAP-UP #129
To:
Addressees
What’s New in 2003?
SUDAN: FEWER CASES REPORTED, PREPARING FOR PEACE
Sudan is expected to report a total of about 35,000 cases of dracunculiasis in 2002, which would be a reduction of –
30% from the 49,471 cases which it reported in 2001, despite similar rates of reporting from endemic villages (66%,
63%) in the two years (Figure 1). Much of the reported reduction in cases is from the areas controlled by the
Government of Sudan in the south (-68%), compared to the areas controlled by the Sudan Peoples Liberation
Movement (SPLM) in the south (-15%) of the country. The reasons for the substantial reduction in reported cases
are not entirely clear, but this is the largest such reduction reported since Sudan’s program intensified during the
“Guinea Worm Cease Fire” in 1995: reported cases fell by –17% in 2000 and by –10% in 2001. In January-October
2002, the northern states have reported 57 indigenous cases, plus 27 cases imported from villages in the south of the
country. In addition to the cases exported to northern Sudan, endemic areas in southern Sudan have exported 50
cases to Ethiopia, Uganda and Kenya in January-November 2002.
Figure 1
Sudan: Percentage of Endemic Villages Reporting and Number of
Guinea Worm Cases Reported, 1997 - 2002*
5744
6406
70,000
6892
7898
6040
6240
Number of
Endemic Villages
100
66,097
60,000
49,471
Number of cases reported
50,000
43,596
47,977
66%
63%
40,000
60
35,000
30,000
44%
40
39%
20,000
34%
36%
20
Cases
10,000
Reporting
0
0
1997
1998
1999
2000
2001
2002*
*projected
Percent Endemic Villages Reporting
80
54,890
In 2001, Sudan distributed more cloth filters for household use (848,576), and far more pipe filters for personal use (7.8
million) than ever before. The program has already distributed more cloth filters than that in January-October 2002:
978,245. (About 3 million additional pipe filters and 860,000 pipe filter replacement clothes were distributed in 2002.)
The proportion of accessible endemic villages with cloth filters in all households increased from 63% in 2001 to 68%
in 2002. Sudan also expanded broadcasts of health education messages in local languages during 2002. The
evaluation of the pipe filter project is still underway in two areas of Western Equatoria State, but provisional reports
from three relatively unstable areas in Warab and Lakes (Buheirat) States, indicates that 98% of those surveyed knew
about cloth filters, 94% knew about pipe filters, and 80% of surveyed households actually had a cloth filter, but only
50% of individuals interviewed said they had received a pipefilter. This program now has identified 27 operational
containment centers in six northern states to facilitate containment of cases there (75% of all cases reported in the
northern states in January-October 2002 were reportedly contained). The status of interventions in the southern
states of Sudan during the last 4 years is summarized in Table 1.
Table 1
Status of Performance Indicators for Guinea Worm
Interventions in Southern States of Sudan, 1999 - 2002
Number of Endemic Villages
Reporting Monthly
Trained Village Volunteer
Guinea Worm Health Education
Full Filter Coverage
Any Safe Water
Using Abate
1999
7,197
44%
67%
60%
26%
37%
2%
2000
5,153
38%
54%
54%
28%
45%
3%
2001
5,978
66%
84%
85%
62%
61%
1%
2002*
6,032
63%
94%
90%
68%
58%
2%
Cases of Guinea Worm Disease Reported
Contained/ managed
65,812
51%
54,734
42%
49,339
49%
33,792
53%
*Provisional, January – October 2002
Planning continues for escalating the fight against dracunculiasis in post-war Sudan. Overall strategy calls for
emphasizing health education and distribution of cloth filters after rapid surveys of newly-accessible areas, and
giving special attention to the highest endemic areas of southern Sudan and areas that are most likely to export cases
to neighboring countries. The Polio Eradication Program has agreed to include the question, “Has anyone in this
village had Guinea worm disease in the past year?”, with a picture of an emerging Guinea worm, on the vaccination
forms to be used in the National Immunization Days in March 2003. Surveys of long-inaccessible populations in the
Nuba Mountains area of South Kordofan State are continuing (funding provided by the US Agency for International
Development), and are scheduled to extend to SPLM-controlled zones beginning in February. The Carter Center will
provide training in conflict resolution for health workers from the Nuba mountains in January. The Carter
Center/Global 2000 is also helping the Sudanese program to identify the major camps for Sudanese refugees in
neighboring countries, and the main camps for internally displaced persons in Sudan, in order to ensure that the
camps’ inhabitants are educated and otherwise prepared to avoid getting or dispersing dracunculiasis as they return
to their homes when Peace comes. The program is also preparing a Sudanese version of “Guinea worm cloth”.
OUTSIDE SUDAN: MOSTLY GHANA, NIGERIA, TOGO AND MALI
As indicated in Table 2, Gh ana, Nigeria, Togo and Mali together have reported 89% of all cases of dracunculiasis
outside of Sudan so far in 2002. And one half (50%) of all those cases are concentrated in only 13 districts: 7 in
Ghana, 3 in Nigeria, 2 in Mali and 1 in Togo (Table 2; map). The Carter Center/Global 2000 is providing technical
assistance to each of these thirteen districts.
Data reported so far in 2002 are summarized in table 3, figures 3 and 4, and the map of West Africa (see insert).
Table 2
Status of Selected Interventions in Key Endemic Districts*
District
Country
reported
Cases
(# months)
Case Containment Centers
Radio Messages
began
quantity
Worm Weeks
completed
projected
Zab-Tat
Ghana
777
(10)
12/02
3
Haho
Togo
556
(11)
3/02
1
Yes
Nanumba
Ghana
542
(10)
12/02
2
Yes
10/02
2/03
Tamale
Ghana
487
(10)
12/02
2
Yes
10/02
2/03
East Gonja
Ghana
427
(10)
12/02
3
Yes
10/02
2/03
West Gonja
Ghana
387
(10)
12/02
3
Yes
10/02
Ibarapa North
Nigeria
387
(11)
12/02
1
Yes
Ado
Nigeria
322
(11)
0
Yes
Gao
Mali
315
(10)
Guma
Nigeria
311
(11)
0
Atebubu
Ghana
264
(10)
0
11/02
10/02
8/03
2/03
none
1/03
1
Kintampo
Ghana
261
(10)
12/02
1
Ansongo
Mali
241
(10)
0
* these 13 districts reported 5,277, or 50% of all cases outside Sudan for this period (10,638)
2/03
none
3/03
Yes
1/03
6/02
1/03
none
In Ghana, increased technical assistance and personnel (see Guinea Worm Wrap-Up #127) have helped the program
to strengthen supervision in the remaining endemic areas. One result is more complete active surveillance, and the
detection and reporting of substantially more cases since May 2002 than in the same months of 2001. Comparable
intensified measures have also been taken to strengthen containment of the cases, with 15 case containment centers
operating as of December 2002. The program will implement additional “Worm Weeks” of intensive health education
and community mobilization in the seven highest endemic districts in January and February 2003, with support from
UNICEF/Ghana, The Carter Center, and U.S. Peace Corps. This will include the first such Worm Week ever held in
Atebubu District, which has not yet identified a facility to contain and care for dracunculiasis patients (Table 2).
Ghana’s reported case containment rate was 68% in 2001 and is 69% so far in 2002.
Ghana’s Ministry of Health has designated Chief Gilbert S.S. Bakari, who is also an agricultural engineer, as eminent
spokesperson and advocate for the program in the Northern Region. He has already begun to record messages to be
broadcast by radio. Welcome, Chief Bakari!
Nigeria has improved its filter coverage (from an average 84% endemic villages with filters in all households in 2001
to 98% in 2002) and the proportion of endemic villages with at least one source of safe drinking water (from 45%
average in 2001 to 57% in 2002). The Nigeria program also began implementing Worm Weeks for the first time in 2002
(it needs to extend these to Ibarapa North and Guma LGAs immediately). The reported rates of case containment
during 2002 have not improved since 2001 (65% both years). A case containment center began operating in Ibarapa
North Local Government Area (LGA in December 2002 (Table 2). Former Nigerian head of state General (Dr.) Yakubu
Gowon made a return advocacy visit to Ebonyi State in December, and he plans to re-visit Benue State (locus of Ado
and Guma LGAs –see Table 2) early in 2003. Unfortunately, the dramatic reductions in cases achieved by Ebonyi
State during its peak transmission season early in 2002 have been followed by increases in cases in Benue (810 cases
in January-November 2002, a 49% increase since 2001), Oyo (623 cases, a 205% increase), and Niger (350 cases, a
169% increase) States during their peak seasons later in the year. The Nigerian program confronts the same
Table 3
Number of cases contained and number reported by month during 2002*
(Countries arranged in descending order of cases in 2001)
NUMBER OF CASES CONTAINED / NUMBER OF CASES REPORTED
COUNTRIES
REPORTING
CASES
JANUARY
674
FEBRUARY
567
/
SUDAN
607
/
1148
350
/
/
/
744
147
/
TOGO
/
191
6
/
103
26
/
BURKINA FASO
/
10
4
/
MALI
5
6
5
/
/
/
/
BENIN
28
11
/
MAURITANIA
/
0
0
/
/
/
0
/
/
/
/
/
/
7
7
/
3
1
1
2
/
3
/
4
/
/
44
/
157
23
/
5
/
/
1
40
0
/
5
197
146
/
0
/
/
1
0
14
3
/
5
28
/
/
4
/
/
5
236
187
43
4
12
2
/
1
0
19
/
5
3
/
38
/
5
829
/
3
26
/
/
141
83
2
/
5
0
2
1
4
2
0
1
0
1
/
/
72
/
/
558
/
0
15
/
479
22
30
3
7
/
37
205
/
/
1
2
/
0
0
1
/
5
/
/
2
1341
45
37
30
/
420
102
301
/
2
/
212
/
23
40
/
4
5
0
0
0
UGANDA
8
/
0
3
/
178
19
5
/
1
/
0
/
2
10
43
/
139
/
4863
31
64
/
25
4
/
5
/
0
/
1
24
9
5
0
/
7
/
0
/
10
52
8
6
/
/
817
209
/
/
776
/
176
3284
/
63
48
/
3240
136
70
/
77
/
427
534
/
57
46
23
/
4
0
/
91
28
0
/
23
/
86
/
178
80
33970
432
128
/
30
/
2129
245
/
51
236
/
5
/
0
0
52
COTE D'IVOIRE
5
/
42
83
2
/
0
6
91
/
32
/
0
NIGER
/
0
139
45
81
57
/
368
/
/
178
319
175
/
210
/
92
66
21
4
/
/
27
22
29
4
/
/
40
20
/
105
TOTAL*
17939
/
2341
163
246
69
92
/
4391
/
119
409
1367
/
107
198
/
55
2845
3618
/
158
464
SEPTEMBER OCTOBER NOVEMBERDECEMBER
/
125
314
/
34
1708
6589
/
281
367
AUGUST
/
143
244
/
12
3391
6429
/
305
412
JULY
/
222
232
/
19
3106
5422
/
283
680
JUNE
/
205
220
/
71
2728
1612
/
303
/
MAY
/
152
336
389
GHANA
854
1139
148
647
497
APRIL
/
1103
195
NIGERIA
MARCH
15
/
0
/
/
0
21
0
/
/
/
/
/
/
/
/
/
/
/
/
/
CAR
0
0
0
/
ETHIOPIA
2
/
0
1
/
0
11
/
3
6
/
6
5
/
11
6
/
7
6
/
5
1
/
6
2
/
6
0
/
1
40
/
2
/
0
1
/
/
/
/
/
/
/
/
CAMEROON
3
/
KENYA
/
*
3
/
1
1804
% CONTAINED
/
/
/
/
/
1
1
TOTAL*
47
1
63
2871
/
3
1312
/
4
1137
/
57
2319
/
3
1343
/
61
1876
/
59
2295
12
/
4
3363
/
1
1
53
6337
/
/
/
/
/
1
3746
/
/
3867
/
51
7356
12
2148
/
7380
52
3397
/
49
4371
2346
/
65
5205
1125
/
3753
63
1
/
1792
63
PROVISIONAL
Shaded cells denote months when zero indigenous cases were reported. Numbers indicate how many imported cases were reported and contained that month.
Benin reported 4 cases imported from Togo in March and 1 in June,and 2 in August plus 1 case each imported from Ghana in March and April, respectively.
Uganda reported 1 case imported from Sudan in April, 2 in May, 2 in June, 2 in August, and 5 in September.
Ethiopia reported 1 case imported from Sudan in March, 5 in May, 4 in June, 3 in July, 4 in August, 3 in September, 1 in October, and 2 in November.
Cameroon reported 1 case imported from Nigeria in October.
Kenya reported 1 case imported from Sudan in January, 3 in March, 3 in April, 4 in May, and 1 in September.
25589
/
1
100
/
45556
56
Distribution of 11,516 Cases of Dracunculiasis in West Africa :January – November 2002*
Number of Cases
0 Cases
1 - 9 Cases
10 - 99 Cases
100 + Cases
Figure 2
Distribution by Country of 45,428 Indigenous Cases of Dracunculiasis Reported During 2002*
Number of cases
0
10,000
20,000
30,000
Sudan (11)
33,970
4,863
Ghana (11)
Nigeria (11)
3,284
1,315
Togo (11)
825
Mali (11)
Burkina Faso (11)
547
Niger (11)
228
Cote d'Ivoire (12)
192
Benin (11)
134
Mauritania (11)
40,000
40
Ethiopia (12) 24
Uganda (11) 6
* Provisional
(11) denotes the number of months for which reports have
been received, e.g., January -November
Figure 3
Distribution of 45,555 Cases of Dracunculiasis Reported During January - November 2002*
Nigeria
7%
Others
7%
Ghana
11%
Sudan
75%
Figure 4
Percentage of Endemic Villages Reporting
and Percentage Change in Number of Indigenous Cases of Dracunculiasis
During 2001 and 2002*, by Country
COUNTRY
ENDEMIC VILLAGES
REPORTING
1+ CASES
2001
UGANDA (11)
%
REPORTING**
% CHANGE : 2001 - 2002
CASES REPORTED
2001
% REDUCTION
2002
-100
% INCREASE
-50
0
50
8
100%
51
6
25
100%
91
40
202
95%
1009
547
NIGER ( 11)
50
100%
386
228
NIGERIA (11)
733
99%
4989
3284
3921
70%
48240
33970
COTE D'IVOIRE (112)
28
100%
226
192
BENIN (11)
39
96%
119
134
13+
TOGO (11)
180
100%
1153
1316
14+
GHANA (11)
779
98%
4243
4864
15+
MALI (11)
120
100%
637
825
ETHIOPIA (12)
10
100%
10
24
CENT.AFR.REP
27
NR
TOTAL*
6122
78%
61154
45428
TOTAL (- Sudan)*
2201
98%
12914
11458
MAURITANIA (11)
BURKINA FASO (11)
SUDAN (11)
-88
-56
-46
-41
-34
-30
-15
30 +
140 140 +
NR
* provisional
(11) Indicates month for which reports were received, i.e., Jan. - Nov. 2002
NR No Report
-26
-11
challenges in these three states as in Ghana and other programs’ residual endemic areas: poor supervision, bad
surveillance, and failure to contain effectively those Guinea worm cases that the program does know about. Overall,
Nigeria reduced its cases by –34% in January-November 2002.
In Togo, where the peak transmission season extends from October through February, the number of cases reported
was reduced by –24% in November, following a reduction of –32% in October 2002. Following monthly increases for
most of the year, this downturn may reflect the impact of more effective isolation of cases in case containment
centers, which Togo began using in August 2001. The 15 villages where this strategy was employed in November
2001 reported –89% fewer cases in November 2002. The village of Kpatala (Ogou Region), which experienced an
explosive outbreak of 115 cases in November 2001, detected only 4 cases in November 2002, and Ogou Region, which
reported more cases (830) than any other region in the country in 2001 has reduced its cases by –49% in JanuaryNovember 2002. Togo’s main endemic area now is Haho District, where reported cases have increased 369%, to 558,
so far in 2002. Togo reportedly contained 85% of its cases in October 2002, but only 64% in November. Of the 136
cases that were contained in November, 96 were referred to a containment center. Overall, Togo reportedly contained
62% of its cases in 2001 and 61% so far in 2002. The presence of so many cases in Ghana’s Zabzugu - Tatale District,
on the border with Togo, is an extreme danger to Togo’s Program, which has been surprised several times before as a
result of weak surveillance and inattention in non-endemic or low endemic districts.
Number of cases
Mali’s Gao and Tinmuktu Regions have reported increases in cases since 2001, eg. see figure 5, and are now the
areas where transmission of the disease is the most intense. A total of 829 cases have been reported from Mali so far
during 2002 and 93% of these cases have been reported from contiguous Gao (Gao Region), Ansongo (Gao Region),
and Gourma Rharous (Timbuktu Region) Districts, where cases among nomadic Tamashek populations occur in
common with similar groups in neighboring parts of Niger and Burkina Faso (see Guinea Worm Wrap-Up #128). Dr.
Ernesto Ruiz-Tiben of The Carter Center/Global 2000 visited Mali from 26 November to 3 December to meet with
officials in Bamako and Gao, including the national coordinator (Dr. Issa Degoga), and Global 2000’s resident
technical advisor (Dr. Mamdou Bathily), and to assess epidemiologic and programmatic aspects of activities in this
area. He also attended a monthly meeting of Mali’s Intersectoral Committee for Guinea Worm Eradication. He made
several urgent recommendations that are intended to Figure 5
Number of Cases of Dracunculiasis Reported from Gao Region: 1995 - 2002*
strengthen the focus and effectiveness of
2,500
operations in this difficult area. Mali’s Guinea Worm
Eradication Program will hold its annual national
2,000
1,950
review meeting in Gao during the week of January
21-25, and will invite national coordinators from the
programs in Niger and Burkina Faso to attend. The
1,500
U.S. Peace Corps has agreed to have four of its
volunteers in Gao Region participate in eradication
1,000
activities there. Mali has halted transmission of
dracunculiasis in most of the remainder of the
560
556
country. Of the 16 indigenous cases reported in
476
500
Mopti Region in January-October 2002, 15 occurred
320
215
139
in one village, and all but one were reportedly
132
0
contained. Another 20 cases were imported into
1995
1996
1997
1998
1999
2000
2001
2002*
* Provisional data based on reports from January - October 2002
Mopti from Timbuktu or Gao Region.
Mali
reportedly contained 51% of its cases in 2001 and 57% so far in 2002.
VESTEERGARD-FRANDSEN DONATES FILTERS FOR MALI AND GHANA
Mr. Torben Vestergaard Frandsen, director of Vesteergard-Frandsen,
has agreed to fabricate and ship free of charge 14,000 conical-shaped
nylon filters to Mali and provide 500 square meters of nylon cloth to
Ghana. This is Vestergaard-Frandsen's 2003 donation of 3,500
square meters of nylon cloth to the global campaign to eradicate
dracunculiasis, and the third such donation, following donations of
3,000 square meters each in November 1998 and June 2000. Thank you Torben!!
IN BRIEF:
Benin reported 37 indigenous cases and 7 imported cases (6 from Togo, 1 from Ghana) in November. This is a
reduction of –47% from the 70 indigenous cases that were reported during the unexpected explosive outbreak mainly
in the Tchetti area of Benin in November 2001, in common with the simultaneous large outbreak in the nearby village
of Kpatala in Togo (see above). It thus seems unlikely that 112 of the 114 cases from that area of Benin in November
and December 2001 were contained, as reported, or else the program did not detect all of the cases that were
occurring then. In January-November 2002, 146 (93%) of Benin’s 157 cases (including 22 imported cases) have
reportedly been contained.
MEETING
The 8th Meeting of Program Managers of Guinea Worm Eradication Programs will be held in Kampala, Uganda on
April 1-4, 2003.
RECENT PUBLICATIONS
Hopkins DR, Withers PC Jr, 2002. Sudan’s war and eradication of dracunculiasis. The Lancet (Supplement) 360
(December): s21-22.
2002 NOBEL PEACE PRIZE
“…The Carter Center has in cooperation with other organizations headed a number of
important health campaigns. So far the best results have been achieved in the fight against
guinea worm infection….” Statement by Gunnar Berge, Chairman of the Norwegian Nobel
Committee in introducing former US President Jimmy Carter, winner of the Nobel Peace Prize for
2002, at the Nobel award ceremony on Oslo, Norway on December 10, 2002.
Inclusion of information in the Guinea Worm Wrap-Up does not
constitute “publication” of that information.
In memory of BOB KAISER.
For information about the GW Wrap-Up, contact Dr. James H. Maguire, Director, WHO Collaborating Center for
Research, Training, and Eradication of Dracunculiasis, NCID, Centers for Disease Control and Prevention, F-22,
4770 Buford Highway, NE, Atlanta, GA 30341-3724, U.S.A. FAX: 770-488-7761. The GW Wrap-Up web location has
changed to http://www.cdc.gov/ncidod/dpd/parasites/guineaworm/default.htm
CDC is the WHO Collaborating Center for Research, Training, and Eradication of Dracunculiasis.